The Role of Primary Care Physicians

by Hoover Adger, Jr., MD, MPH

There are an estimated 28.6 million Americans who are children
of alcoholics (COAs), nearly 11 million of them under the age of 20.

Many of these children are exposed to chaotic family environments which lack consistency, stability
or emotional support. Many will go on to develop alcoholism, other drug
problems, and/or other serious coping problems. Most will have seen
their pediatrician, adolescent medicine or family practitioner multiple
times along the way. These children should not have to suffer in silence
and need to know that help is available.

Children and adolescents
living in families where there is an alcohol or other drug abusing
parent or other caretaker often develop unhealthy living patterns. They
may not learn to trust themselves or others, how to handle uncomfortable
feelings, or how to build positive relationships. Children and
adolescents who lack these skills are at higher risk for school failure,
depression, increased anxiety, as well as trouble with alcohol and other
drugs.

Children of alcoholic and other drug abusing parents often
come to the pediatrician, adolescent health or other primary care
provider with recurring and vague symptoms, such as fatigue, abdominal
pain, or musculoskeletal complaints, which may be indicative of
psychosomatic illness. In addition, they may suffer from accidental
injury, verbal abuse, physical abuse or sexual abuse associated with
parental drinking or drug use. Poor communication, permissiveness,
under-socialization, neglect and violence-all potentially
devastating-are common in children who live in alcoholic families.
Primary health practitioners can help reduce or prevent alcohol and
other drug related impairment by providing education, identifying
affected youth and families and by initiating early intervention.

Role of the Child/Adolescent Health Practitioner

The
Committee on Substance Abuse of the American Academy of Pediatrics
recommends that pediatricians include substance abuse in their
anticipatory guidance to all children and adolescents. The committee's
guidelines reiterate that practitioners should possess the skills
necessary to recognize risk factors and signs of substance abuse in
their patients, and should be able to evaluate the nature and extent of
alcohol use and to offer appropriate counseling or referral. The
Guidelines for Adolescent Preventive Services (GAPS) established by the
American Medical Association recommend both primary (e.g., patient
education and anticipatory guidance) and secondary (e.g., early
intervention) preventive strategies to reduce adolescents' use of
alcohol and other drugs. These measures include screening of all
children and adolescents and the utilization of brief counseling and
referral as needed. GAPS also recommends that practitioners routinely
ascertain their patients' risk factors (including a family history of
alcoholism) in the medical history and conduct screening evaluations for
all school-aged children and adolescents. Clearly, there is a need to
extend these recommendations to include the identification of alcohol
and other drug related problems in the family.

Discussions about
prevention of alcohol abuse and related problems should begin with the
prenatal visit by focusing on the responsibility of parents, parental
lifestyle, and effects of parental alcohol use on the fetus, infant,
child and adolescent. Parents serve as important role models for their
children. Children's attitudes and beliefs regarding alcohol develop
early in life, often by age 7 or 8. Parents need to be aware that their
attitudes and beliefs can strongly influence and play a major role in
shaping their child's behavior. Hence, it is important for the health
provider to explore the attitude of the family toward alcohol use and
provide basic education appropriate to the age and development of the
child.

Anticipatory guidance about alcohol use should begin early in
childhood when family standards and values are being assimilated.
Well-child visits during the early school years provide many
opportunities to discuss alcohol. Pediatricians and other primary care
practitioners should routinely include an assessment of alcohol risk
factors (including a family history of alcoholism) in the medical
history.

Physicians can initiate or enhance the dialogue between
children and their parents by asking if alcohol use is being discussed
in school, inquiring about the specifics of what is being taught, and
assessing if the child understands the messages that are being
delivered. It is important to ask if alcohol use is discussed among
friends, whether alcohol is present in the child's environment, about
their perceptions of why some people use alcohol and whether or not
alcohol use is harmful.

In addition to providing anticipatory
guidance, the primary care provider can play an active role in general
prevention programs directed at children and adolescents. Pediatricians,
adolescent medicine specialists, family practitioners and others can act
as important advocates for appropriate community and school-based
prevention approaches and in educating patients and parents, ensuring
that local programs are culturally relevant and appropriate for the
various communities and populations they serve.

Routine
Screening

All child/adolescent health practitioners should screen
and perform an initial evaluation of their patient's use of alcohol
and/or other drugs and determine indications for further assessment and
intervention. They should also screen for alcohol and drug related
problems in the family. A primary task of initial screening and
evaluation is to determine if the use of alcohol and other mood altering
substances is associated with identifiable consequences and if such use
is causing behavioral impairment. Information gathered should help to
decide if there is a need for further assessment or exploration of
additional problems. Physicians need to keep in mind that screening is
an important and time-efficient first step to identifying the existence
of a problem, but that if a problem is identified, it does not mean that
they have to "fix it." Help is available to assist them.

In addition
to being useful for screening about an adolescent's alcohol use
directly, one can use the questions to provide a proxy report regarding
another person. They can be adapted for inquiry about alcohol use of a
parent or other adult. For example, the CAGE questions could be used in
the following manner with the child or adolescent who is not using
alcohol or other drugs, but seems concerned about a parent's use of
alcohol:

Do you think your mom/dad needs to Cut down on
their alcohol use?

Does your mom/dad get Annoyed at comments from
other people about his/her drinking?

Does your mom/dad ever
feel Guilty about his her drinking?

Does your mom/dad ever
take a drink early in the morning as an Eye-opener?

The ability to
use the CAGE in this manner offers the potential for great flexibility
for the pediatric/adolescent encounter and allows for a comfortable way
of collecting pertinent screening information about or from patients and
parents.

While routine screening for alcohol use may be a desirable
goal, much will have to change before it becomes a reality. Physicians
and other health professionals in training need to develop a sense of
responsibility and optimism toward their patients' alcohol problems and
confidence in their clinical skills related to caring for patients with
these problems. Numerous studies show that physicians are uncomfortable
with and report a need for additional training in screening and
management of alcohol related problems. Hence, educational programs need
to be available to help primary care practitioners develop the clinical
skills to assess and manage patients with alcohol problems. At a
minimum, curricular time should be devoted to alcohol related issues in
medical schools, residency training programs and continuing medical
education courses.

To this end, NACoA has embarked on an initiative
to assist primary care practitioners who care for children and
adolescents so that appropriate awareness of, and interventions directed
at, protecting the physical and mental health of children and
adolescents can become a routine part of their health care.

Conclusion

Primary care physicians encounter a significant number
of children, adolescents, and families who are affected by alcoholism
and other drug related problems. The challenge before health care
providers is to identify individuals early in their involvement and to
intervene in a timely and meaningful manner. An appreciation of the
magnitude of the problem among youth and families and the role of the
primary care practitioner in prevention, management, and treatment is
vital.

Hoover Adger, Jr., MD, MPH, is Professor of Pediatrics and Associate
Director of Adolescent Medicine at Johns Hopkins Hospital, Baltimore, MD. He
is a current member of the NACoA Board of Directors and the immediate past Deputy
Director in the federal government’s Office of National Drug Control Policy(ONDCP).

Note: You are encouraged to print this article and share it with
your family physician or pediatrician.